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Version 10.2015
1
Handbook on Clinical Practice Guideline
Development
Version 10.2015
IDSA reserves the right to make changes and/or improvements to any of the information herein without notice. 2
PURPOSE
The IDSA Standards and Practice Guidelines Committee (SPGC) have overseen the
creation of this Handbook to assist IDSA-sponsored guideline expert panels in navigating
through the often complex task of creating clinical practice guidelines. The bulk of this
document consists of tools to assist guideline developers in interpreting and applying the
methodology.
IDSA understands the challenges in applying a uniform methodology to guidelines that
represent diverse diseases, conditions and interventions. In all cases, expert panel members
should familiarize themselves thoroughly with this handbook, as these methods and standards
provide the framework for guideline creation.
This handbook is to be considered a living document and will be updated as needed at the
discretion of the IDSA SPGC.
CLINICAL PRACTICE GUIDELINES
Definition of Clinical Practice Guidelines
Clinical practice guidelines are defined as “Clinical practice guidelines are statements
that include recommendations intended to optimize patient care that are informed by a systematic
review of evidence and an assessment of the benefits and harms of alternative care options [1].”
Guidelines are written to improve the quality of care, to improve the appropriateness of care, to
improve cost-effectiveness, and to serve as educational tools.
The goal is not to create standards of care; however, other organizations may choose to
adopt these guidelines or components thereof for such purposes. Practice guidelines, however,
are never a substitute for clinical judgment. Clinical discretion is of the utmost importance in the
application of a guideline to individual patients, because no guideline can ever be specific
enough to be applied in all situations [2].
Clinical Practice Guidelines and Quality
Practice Guidelines are widely used to help promote efficient and effective healthcare by
improving process and patient care outcomes. Guideline quality is paramount to their credibility
and implementation by the intended users. To help ensure that its guidelines are of sound
quality, the IDSA looks to the Appraisal of Guidelines Research and Evaluation Collaboration
(AGREE) self-assessment tool (AGREE Instrument), which provides a framework for assessing
the methodological rigor and transparency of clinical practice guidelines [3].
The AGREE II instrument employs 6 domains of quality [3]:
1. Scope and purpose – refers to overall aim of the guideline, specific clinical questions and
target population;
2. Stakeholder involvement – refers to the extent to which the guideline represents the
views of its intended users;
3. Rigor of development – refers to the process used to gather and synthesize the evidence;
methods used to formulate the recommendations and to update them;
4. Clarity and presentation – refers to language and the format of the guideline;
5. Applicability – refers to organizations, behavioral and cost implications of applying the
guideline;
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IDSA reserves the right to make changes and/or improvements to any of the information herein without notice. 3
6. Editorial independence – independence of the recommendations and acknowledgement of
possible conflict of interest
GUIDELINE DEVELOPMENT PROCESS
The process as outlined in the following pages will provide guidance to the guideline
expert panel and help to minimize potential biases, increase confidence by end-users resulting in
increased uptake.
Topic Proposal
The clinical practice guidelines development program falls under the auspices of the
SPGC. While the SPGC is charged with the review and approval of guideline topics and
guideline drafts, actual guideline development is performed by topic-specific expert panels.
The SPGC will consider guideline topic proposals from any IDSA member. Proposed
guideline topics will be chosen based upon the impact that they will have on the prevention,
diagnosis and/or treatment of infectious diseases.
IDSA members who submit topic proposals are required to submit a 3-4 page narrative
proposal that is organized around a series of the following questions:
1. What is the proposed title of the guideline?
2. What is the target patient population, target provider audience and the issue in
question?
3. Is the burden/importance of the condition/intervention large enough to warrant the
development of a document (prevalence/incidence should be included)?
4. Is there uncertainty/controversy about the relative effectiveness of the available
clinical strategies for the condition(s) for which the document is proposed?
5. Is there a perceived or documented variation in practice management of a given
condition/use of health care intervention?
6. Is there sufficient scientific evidence of good quality to allow development of
document (i.e., randomized controlled trials (RCT))? If there is limited, high-quality
information such that more definitive, evidence-based recommendations will not be
possible, please outline how an IDSA document will still be of significant utility to
IDSA members even given this limitation.
7. Are there existing documents (e.g., guidelines on the proposed topic?). It is critical
that the SPGC be aware of existing guidelines on the same topic to avoid duplication
of efforts. Other groups’ guidelines, if judged to be methodologically sound by the
SPGC, can be submitted for endorsement consideration.
8. If an IDSA document were to be developed as a result of your proposal, assuming
appropriate dissemination, do you believe that it would make a significant impact on
clinical decision-making/clinical outcomes and/or reduce practice variation?
Topic Review and Approval
After a topic proposal has been submitted to the IDSA office, it will be considered for
approval by the SPGC, which meets at regular intervals. The Committee must come to consensus
on the following:
Whether or not to develop the guideline
If the proposed topic benefits the IDSA membership at large
If the document can be completed in a timely manner
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IDSA reserves the right to make changes and/or improvements to any of the information herein without notice. 4
If there is a need for this information in a patient care setting
Proposed Timeline/General Process Overview
The process of developing a clinical practice guideline is detailed and timelines may vary
depending on the scope of the topic. Awaiting new developments or data will prolong the
process and should be avoided. The recommended time from the first expert panel
meeting/conference call to submission of the guideline to the SPGC for approval is
approximately 18 months.
In collaboration with IDSA staff, target completion dates for guideline development
milestones will be assigned. The following are the steps that need to be carried out:
Panel Chair/Member Clearance
1. SPGC identifies potential panel chair (if update, may be former chair if he/she passes
conflict screen).
2. Disclosure of interests form is completed and submitted for review by SPGC chair,
SPGC liaison to the panel and Board liaison.
3. If approved, panel chair proposes panel members (and if applicable, collaborating
organizations) to the Chair of the SPGC for approval/additions
4. Disclosure of interests form is completed and submitted for review by SPGC chair,
SPGC liaison to the panel and Board liaison.
Development Process
5. Initial panel teleconference held to:
a. define clinical questions
b. decide specific roles/writing assignments of each member (i.e., specific
subtopic or question to be considered)
c. Discuss process/milestones
6. Literature search is carried out by medical librarians. Yield provided to the panel.
7. Panel members review abstracts and select those that likely meet inclusion criteria
8. Panel members review full-text articles and make final inclusion/exclusion decisions
9. Panel members draft guideline sections as assigned
10. Panel meets (via conference call) and discusses recommendations
11. Panel reviews and approves first complete draft of guideline
12. Guideline subjected to 3-step rigorous review and approval process
13. Guideline submitted to CID for Publication
14. IDSA staff coordinates development of clinical tools including pocketcards and
mobile device versions
Expert Panel Composition and Disclosure of Conflicts of Interest
The Expert Panel is charged with guiding the review of the evidence and subsequently,
developing the guideline recommendations and drafting the manuscript.
The SPGC will identify a Chair(s) of the Expert Panel. The SPGC Chair will also identify
an SPGC member to serve as the liaison-advisor to the Expert Panel. The liaison-advisor will
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IDSA reserves the right to make changes and/or improvements to any of the information herein without notice. 5
provide guidance to the Panel on the development, formatting and approval process of the
guideline as well as monitor the progress for purposes of keeping the entire Committee informed.
The Expert Panel Chair will develop a list of potential panel members with expertise in
the guideline topic. The panel chair may also suggest expertise from organizations that may
have valuable input on the guideline.
The average expert panel will consist of 10 - 14 members who will meet regularly via
conference call and during the annual IDSA conference. To the extent possible, ethnic,
geographic, and gender diversity should be a consideration when identifying potential expert
panel members. In addition, the Panel should include:
Clinicians with expertise in the topic area in question (It is recommended that at least
one physician in private practice be included among the panels membership)
Inclusion of a pediatrician whenever the management of children may be considered
(including the listing of antimicrobial dosing for children) (The PIDS liaison to the
SPGC is available to help identify this individual.)
Additional experts (as considered necessary by the SPGC and expert panel) may
include those in the following disciplines:
o Pediatrics
o Epidemiology
o Pharmacology
o Microbiology
o Nursing
o Primary care
o Subspecialty which has a unique interest in the specific field (e.g., urology for
UTI) (see below regarding involvement of stakeholder organizations)
o Hospitalists
o Others as appropriate
Early in the guideline development process, the SPGC encourages Panels to invite
stakeholder organizations (e.g., PIDS, SHEA, ASHP, SIDP, SIS, ACEP, SAEM, AAFP, etc.) to
participate during the guideline development process. This might take two forms:
1. Joint development* (See Section 2.12.2. Stakeholder Review) - Developing a
guideline jointly entails having co-chairs from each organization and having equal
representation on the panel.
2. Endorsement* (See Section 2.12.2. Stakeholder Review) - Endorsement entails either:
a. The review of the end-product by the organization;
b. The addition to the Panel of a member from the potential endorsing
organization and then review of the final product by the organization.
*Both scenarios provide an opportunity for the endorsing organizations to provide
comments and suggest revisions.
Once identified, the SPGC Chair will review and approve the list of potential panel
members. Potential panel members will then receive the following:
E-mail invitation to participate
Disclosure of interests form
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IDSA reserves the right to make changes and/or improvements to any of the information herein without notice. 6
Participation in the guideline development process is pending review and approval
of the disclosure of interests form per the policy below.
IDSA Disclosure of Interests Policy for Clinical Practice Guidelines (Current as of
April, 2012)
Background and Rationale
As the leading organization for physicians, scientists, and other health care
professionals dedicated to promoting excellence in infectious diseases research,
education, patient care, prevention and public health, the Infectious Diseases
Society of America (IDSA) has a special responsibility to support the efforts of its
members to provide quality patient care. One of the primary ways in which IDSA
fulfills this responsibility is through the development of clinical practice
guidelines. Public confidence in IDSA guidelines and the process by which they
are developed is dependent on the involvement of experts who make
determinations based on the best available evidence.
In October, 2011, the IDSA adopted the Council on Medical Specialty
Societies (CMSS) Code of Interactions with Companies principles for interactions
with companies as they relate to clinical practice guideline development (Table
1).
The following describes the process and specific criteria used for
disclosure for IDSA guideline development panels* and the management of
potential conflicts of interest. Process and procedures for others relevant to the
guideline development process (Standards and Practice Guidelines Committee
(SPGC) members, Board of Directors, reviewers) are also outlined (Figure 1).
Introduction
All guideline panel chairs and members should act in the best interest of
IDSA, its membership, and the public. Decisions that lead to guideline
recommendations should not be influenced by personal financial interests or by
other extraneous considerations. Each guideline panel member has a high duty
* IDSA participates in or endorses guidelines developed by other organizations with established processes for
disclosure. The administrative management of the guideline, including disclosure and management of conflicts of
interest shall be the responsibility of the collaborating organization. IDSA does not participate in guidelines
developed with funding from commercial entities.
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IDSA reserves the right to make changes and/or improvements to any of the information herein without notice. 7
and obligation to disclose any potential conflict of interest and to abstain from any
decision where a potential conflict of interest exists. A potential conflict of
interest exists if a guideline panel member has a financial or other interest that
might bias his or her decisions or actions concerning matters before the Panel. In
the interest of full disclosure, any relationship with a pharmaceutical,
biotechnology, medical device, or health-related company or venture that may
result in financial benefit to the member should be disclosed to IDSA.
Reporting Timeframe
All disclosures should be for activities and financial
relationships/investments that are current or planned and for the preceding two
years. Current or prior relationships will not exclude candidates however
participation is contingent on the candidates termination of such relationship(s)
prior to their final assignment†.
Criteria for Panel Chair(s)
The prospective chair will complete the IDSA Disclosure of Interests
form. He/she will be free from financial or other interests that might bias his or
her decisions or actions concerning matters before the Panel (see Exceptions
below). Relationships that are both prohibited and acceptable are listed in Tables
2 & 3 respectively.
A prospective chair should disclose, if known, whether an affected
commercial entity has provided financial support to the division, or department
within which the individual conducts clinical research and care. The existence of
such support does not necessarily disqualify the individual from service as a chair,
but will be taken into consideration.
Because IDSA guidelines are subject to periodic revision or updating,
panel chairs must complete and sign the IDSA Panel Chair Agreement
acknowledging their commitment not to become involved in prohibited financial
interests for an additional period of one year after publication of the guideline if
they expect to remain in the chair position. If current financial interests preclude
continuing as chair, these individuals may be considered for service as members
† In some cases, IDSA may agree to allow for current commitments (e.g., speaking engagements) to be honored.
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IDSA reserves the right to make changes and/or improvements to any of the information herein without notice. 8
of the panel for the update (with full disclosure of their current financial or
beneficial interests).
Exceptions
Generally, chairs will not be appointed that have financial interests in or
relationships with affected companies or products. To the extent that the above
restrictions are perceived as inhibiting development of a guideline, in rare
circumstances, an exception may be made. A panel chair may receive research
funding from an affected company that is usual and customary for the efforts
needed to conduct the study, if doing so would ultimately help the panel develop a
better quality guideline. In this instance, the panel chair will be unable to vote on
guideline recommendations that are specifically related to the product about
which his/her research is being conducted. In addition, a co-chair that has no
financial or other beneficial interests must also be selected.
Criteria for Panel Members
In April 2009, the Institute of Medicine (IOM) released its Report on
Conflict of Interest in Medical Research, Education, and Practice. Among its
recommendations, were that Groups that develop clinical practice guidelines
“should generally exclude as panel members individuals with conflicts of
interest.” It further recommends that “In the exceptional situation in which
avoidance of panel members with conflicts of interest is impossible because of the
critical need for their expertise, then groups should limit members with
conflicting interests to a distinct minority of the panel.” The IDSA supports this
goal, and through this expanded policy, is taking steps over time to put in place
development panels with a minority of members with potential or perceived
conflicts of interest. IDSA believes that individuals with expertise in a particular
clinical topic are critical to developing the highest-quality and most informed
practice guidelines.
All prospective panel members will complete the IDSA Disclosure of
Interests form. For the duration of the development of the guideline, at least 15%
of those selected as members of a guideline panel will be free of any conflicts of
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interest and at least 15% will have no financial or other relationships related to the
subject matter under consideration. For the remaining panel members such
relationships do not preclude panel membership. However, it may be determined
that an individual is not eligible to serve as part of the panel because of the nature
and extent/intensity of his or her relationship with an affected company.
Relationships that are both prohibited and acceptable are listed in Tables 2
& 3 respectively.
All considerations will be balanced against the necessity of securing
qualified individuals for participation in guideline development. In situations
where the number of qualified experts is limited, panel members may inevitably
have financial interests. IDSA will address this situation through disclosure of
panel members’ financial interests with publication of the guideline. In addition,
the SPGC will require that panel members with a product-specific financial
interest recuse themselves from specific discussions or votes. Panel chair(s) and
the SPGC liaison to the Panel, will be responsible for determining the need for
recusal. If there is a dispute regarding the necessity of recusal, the Chair of the
SPGC, the Board liaison to the SPGC and if necessary, the COI Task Force of the
Board will determine subsequent resolution. In most cases, concerns raised by
panel members’ financial interests may not mandate recusal depending on the
breadth or specificity of the issues under consideration; that is, a financial interest
may be of less concern where the matter under review is more general and less
product-specific in nature.
Other Criteria for Panel Chair and Members
Occasionally, a panel chair may have a relevant financial interest or
relationship that is not covered by IDSA’s formal disclosure process (e.g., an
intellectual, as opposed to financial conflict). In these situations, the panel chair
should disclose this interest to the Chair of the SPGC and/or the appropriate IDSA
staff member prior to discussion of the guideline.
Participation in the activities of the guideline panel is prohibited until
individual disclosures are reviewed and approved by the Chair of the SPGC,
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SPGC liaison to the Panel, the Board liaison to the SPGC and if necessary, the
COI Task Force of the Board. Assessment of disclosed relationships for possible
COI will be based on the relative weight of the financial relationship (i.e.,
monetary amount) and the relevance of the relationship (i.e., the degree to which
an association might reasonably be interpreted by an independent observer as
related to the topic or recommendation of consideration).
Criteria for Spouse/Dependents
Information regarding the interests of a candidates spouse and dependents
is gathered as part of the disclosure process. Candidates should report, to the best
of their ability, any known interests of his/her immediate family that may be
related to the guideline topic under consideration. The extent of the family
members’ relationship will be considered as part of the evaluation of the
candidate.
Criteria for others involved in the guideline development process
Standards and Practice Guidelines Committee
Members of the SPGC serve in a liaison capacity to guideline
development panels. In rare cases, these liaisons may serve as full members of
the development panels. Liaisons who serve in this capacity are required to meet
all criteria set forth above. Members of the SPGC are also charged with the
review and approval of all IDSA guidelines. As with all IDSA Committees,
SPGC members are required to disclose any relationship with a pharmaceutical,
biotechnology, medical device, or health related company or venture that may
result in financial benefit to the member. In addition, SPGC members are
similarly prohibited from the activities outlined in Table 2. Participation in the
activities of the SPGC is prohibited until disclosures are reviewed and approved
by the Chair of the SPGC.
Criteria for Reviewers
External “Peer” Reviewers
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IDSA reserves the right to make changes and/or improvements to any of the information herein without notice. 11
The Editor of Clinical Infectious Diseases will identify at least 3 external
“peer” reviewers to review and comment on the draft guideline. Additional
reviewers may be identified by the SPGC Chair.
SPGC Reviewers
The SPGC Chair appoints Committee members to serve as primary
reviewers of guidelines. Generally, the Chair will select members who have no
financial relationships with affected companies or products to serve as guideline
reviewers.
Board of Directors Reviewers
The Board liaison to the SPGC appoints Board members to serve as
primary reviewers of guidelines. Generally, the Board liaison will select Board
members who have no financial relationships with affected companies or products
to serve as guideline reviewers.
Recusal
To underscore the independence and integrity of the guideline adoption
process, guidelines will be approved only by SPGC and Board members who do
not have financial relationships with affected companies or products. Therefore,
disclosure of any financial relationship with an affected company or product
should be cause for recusal.
Rarely, relationships may be disclosed that, though not financial in nature,
could undermine public confidence in the guideline process. If there is a question
as to whether a particular relationship warrants recusal, a determination will be
made by the SPGC Chair or Board Chair, respectively, with the assistance of
IDSA staff. Any Committee or Board member who discloses a financial interest
in a company or product affected by a guideline should recuse him or herself from
the decision on approval of a guideline. The SPGC or Board member may take
part in initial discussion of the guideline manuscript, recognizing that there may
be additional discussion by remaining members after recusal and before the vote.
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Publication of Disclosure Information
When IDSA publishes a guideline in one of its journals, all disclosures of
panel members will be published concurrently. The following language will
accompany the list of disclosures within the “Acknowledgements” section:
Potential Conflict of Interest: The following list is a reflection of
what has been reported to the IDSA. In order to provide thorough transparency,
the IDSA requires full disclosure of all relationships, regardless of relevancy to
the guideline topic. Evaluation of such relationships as potential conflicts of
interest is determined by a review process which includes assessment by the
SPGC Chair, the BOD liaison to the SPGC, the liaison to the Panel and if
necessary, the COI Task Force of the Board. This assessment of disclosed
relationships for possible COI will be based on the relative weight of the financial
relationship (i.e., monetary amount) and the relevance of the relationship (i.e., the
degree to which an association might reasonably be interpreted by an independent
observer as related to the topic or recommendation of consideration). The reader
of these guidelines should be mindful of this when the list of disclosures is
reviewed.
General Exceptions
IDSA’s goal is to assemble a diverse and well-qualified group of experts
to develop, approve, and adopt guideline recommendations. If required to achieve
this goal, the above procedures may be modified by the COI Task Force of the
Board on a case-by-case basis to the extent necessary.
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IDSA reserves the right to make changes and/or improvements to any of the information herein without notice. 13
Table 1. Principles for Interactions with Companies on Clinical Practice Guidelines (Abstracted from the CMSS
Code)
7.1. Societies will base Clinical Practice Guidelines on scientific evidence.
7.2. Societies will follow a transparent Guideline development process that is not subject to Company influence. For
Guidelines and Guideline Updates published after adoption of the Code, Societies will publish a description of their
Guideline development process, including their process for identifying and managing conflicts of interest, in Society
Journals or on Society websites.
7.3 Societies will not permit direct Company support of the development of Clinical Practice Guidelines or Guideline
Updates.
7.4 Societies will not permit direct Company support for the initial printing, publication, and distribution of Clinical
Practice Guidelines or Guideline Updates. After initial development, printing, publication and distribution is complete, it is
permissible for Societies to accept Company support for the Society’s further distribution of the Guideline or Guideline
Update, translation of the Guideline or Guideline Update, or repurposing of the Guideline content.
7.5. Societies will require all Guideline development panel members to disclose relevant relationships prior to panel
deliberations, and to update their disclosure throughout the Guideline development process.
7.6. Societies will develop procedures for determining whether financial or other relationships between Guideline
development panel members and Companies constitute conflicts of interest relevant to the subject matter of the guideline, as
well as management strategies that minimize the risk of actual and perceived bias if panel members do have conflicts.
7.7. Societies will require that a majority of Guideline development panel members are free of conflicts of interest relevant
to the subject matter of the Guideline.
7.8. Societies will require the panel chair (or at least one chair if there are co‐chairs) to be free of conflicts of interest
relevant to the subject matter of the Guideline, and to remain free of such conflicts of interest for at least one year after
Guideline publication.
7.9. Societies will require that Guideline recommendations be subject to multiple levels of review, including rigorous
peer‐review by a range of experts. Societies will not select as reviewers individuals employed by or engaged to represent a
Company.
7.10. Societies’ Guideline recommendations will be reviewed and approved before submission for publication by at least
one Society body beyond the Guideline development panel, such as a committee or the Board of Directors.
7.11. Guideline manuscripts will be subject to independent editorial review by a journal or other publication where they are
first published.
7.12. Societies will publish Guideline development panel members’ disclosure information in connection with each
Guideline and may choose to identify abstentions from voting.
7.13. Societies will require all Guideline contributors, including expert advisors or reviewers who are not officially part of a
Guideline development panel, to disclose financial or other substantive relationships that may constitute conflicts of
interest.
7.14. Societies will recommend that Guideline development panel members decline offers from affected Companies to
speak about the Guideline on behalf of the Company for a reasonable period after publication.
7.15. Societies will not permit Guideline development panel members or staff to discuss a Guideline’s development with
Company employees or representatives, will not accept unpublished data from Companies, and will not permit Companies
to review Guidelines in draft form.
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TABLE 2. Relationships Prohibited
1. Royalties, licensing fees, patents from any product or device related to the topic under consideration. This
includes patents, the rights for which, have been turned over to an institution but from which the individual
benefits.
2. Serving as an officer, board of directors member or employee of any device, insurance, pharmaceutical or
diagnostic product or commercial entity with a product or device related to the topic under consideration.
3. Representation of any commercial healthcare-related entity (with a product or device related to the topic under
consideration) before FDA advisory committees or in any other interactions such an entity may have with FDA.
4. Any honoraria, gifts or other‡ payments directly received from any relevant commercial healthcare-related
entity§. This includes, participation in speakers bureaus labeled as promotional and/or when any associated
presentation is:
a. content-restricted in any way, including, but not limited to the requirement to use only company-provided
material;
i. paid for by any mechanism other than an unrestricted educational grant to a CME-approved (or other
educational) entity; and/or
ii. product-specific.
5. Any activity not sponsored by the research arm of the company will NOT be allowed. For example, an advisory
board sponsored by the marketing division, even if concentrating on “future research directions”, will NOT be
allowed. In addition, consulting on post-research regulatory issues will NOT be allowed.
6. Stock or equity in any commercial healthcare-related entities (excludes diversified funds).
Table 3. Relationships Allowed
1. Advisory/consultancies when research-related will be considered as a research activity, even if the company
with which you have the relationship, has products related to the guideline. Thus, work with a pharmaceutical
or device company involving study design or service on a Data Safety Monitoring Board WILL be allowed.
Exception, Panel Chair
2. Serving as an investigator on a research study**.
3. Presentations at national or international meetings provided that:
a. Presentations are non-promotional and there should be no involvement of industry in presentation
content. There should be complete intellectual independence with regard to presentation content.
b. There is NO direct payment by industry to an individual for his/her participation (any industry support
of speaker expenses must be through a third-party organization (e.g, IDSA, ICAAC, ATS, etc),
institution, CME or other educational provider.
Exception, Panel Chair
‡ Includes funds for travel/hotel § Relevant to U.S. and International ** If you are a panel chair and conduct research, IDSA may require a co-chair with no relationships/research.
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Figure 1. Disclosure Process for Clinical Practice Guideline Panels (before-during
development)
2. Form Completed and
submitted to IDSA
Approved:
Move to invite other
members of the Panel
Not approved
(conflicted):
Identify replacement (or
unconflicted co-chair) –
repeat step 1
1. IDSA Staff Sends
Invitation & Disclosure
to Prospective Chair*
Chair(s)* Members
1. IDSA Staff Sends
Invitation & Disclosure
to Prospective
Members^
2. Form Completed and
submitted to IDSA
3. Disclosure Form Reviewed by:
SPGC Chair
SPGC Liaison to Panel
Board Liaison to SPGC
~At the discretion of the SPGC Chair, a request may be
made to the Board COI Task Force for further review and
determination
Key:
* Chairs should be without conflict. If not possible, an unconflicted co-chair will be appointed. Chair contract/agreement also
submitted at this time for IDSA file.
^IDSA strives for 15% of panel members to be without any conflicts; 15% should be without any relevant conflicts
See Handbook on Guideline Development for other Policies on Disclosure of interests.
STEP 1 STEP 2
3. Disclosure Form Reviewed by:
SPGC Chair
SPGC Liaison to Panel
Board Liaison to SPGC
~At the discretion of the SPGC Chair, a request may be
made to the Board COI Task Force for further review and
determination
Not approved
(conflicted^):
Identify replacements
Approved:
Move forward with
development process
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Finalize Purpose and Scope
During the first Panel meeting/conference call, the following (much of which will have
been identified and outlined in the aforementioned “topic proposal application”) will be
discussed and agreed upon before moving forward:
1. Definition of the Overall Purpose of Guideline:
The purpose for writing the guideline should be clearly identified and written. It should
be clear to the target provider audience why it is an important topic, why it has been chosen for
review at this time and what impact the guideline is expected to have on the practice of medicine.
Clarification of controversy, proper uses of newer technologic or diagnostic tools, and
appropriate use of pharmaceuticals are examples of appropriate reasons for guideline
development.
2. Identification of Relevant Practice Setting(s):
Specify clearly who the target provider audience is at the beginning of the guideline (e.g.,
hospitals; primary care or specialty care office-based practices).
3. Specification of the Population(s) of Interest:
The targeted patient population should be clearly specified. Consider age, sex, clinical
condition or other factors that might affect the recommendations and then define these
limitations. Consideration should be given to (1) the inclusion of special populations, such as
demographics, pediatric patients, pregnant women, minorities or immuno-compromised
individuals, and (2) how-or whether- the guideline recommendations are altered by these
circumstances. It may be best to propose that a separate guideline be developed to encompass
these groups if the recommendations are significantly different for specific populations.
IDSA guidelines are intended to apply to the North American population due to the
variation in availability of drugs and differences in practice abroad.
4. Specification of the Diagnostic and Therapeutic Options:
Specify clearly the principal diagnostic or therapeutic options that are available and how
they will be explored in the guideline. The reasons why these options were chosen and why other
options were not considered should also be specified. This helps ensure that the document is
succinct and focused.
5. Identification of Relevant Primary and Secondary Outcome(s):
Specify clearly the relevant primary and secondary outcomes (e.g., disease-free survival,
overall survival, treatment toxicity, cost-effectiveness, quality of life).
6. Specification of the Clinical Questions to be Addressed:
Clinical questions flow from the broad guideline topic proposed and help focus the
evidence review. In the context of making recommendations it is helpful to conceptualize all
clinical questions as either:
FACTS (e.g. prognosis, frequency of symptoms, etiology, pathophysiology etc.) – they
provide important background information, but do not lead to recommendations per se
and are not graded
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Examples:
o How do children differ from adults in disease manifestation?
o What is the rate of spontaneous resolution in ABRS?
o What are some suppurative and life-threatening complications of sinusitis?
OR
ACTION (e.g. diagnosis, treatment, other management) – they do lead to
recommendations and are graded.
Examples:
o Is there a role for sinus aspiration and quantitative cultures?
o How long should antimicrobials be continued?
o Which antibiotics are preferred?
These latter questions about ACTION lead to recommendations.
Q: How long should antimicrobials be continued?
A: For 2 weeks.
Recommendation: We recommend that antimicrobials be continued for 2 weeks
[strong recommendation, moderate quality evidence].
There is a well accepted way of framing the questions about action (addressing
alternative management strategies for which GRADE is relevant) popularly known as
PICO. PICO mandates carefully specifying the patient population (P), the intervention of
interest (I – either diagnostic or therapeutic), the alternative intervention or comparator
(C), and the outcomes (O) of interest (See Figure 2)††
.
Examples:
A question “What about decongestants?” could be broken into several precise questions:
Q1: Should oral decongestants versus no oral decongestants be used in adults
with acute bacterial rhinosinusitis?
Q2: Should oral decongestants versus no oral decongestants be used in children
with acute bacterial rhinosinusitis?
Q3: Should intranasal decongestants versus no intranasal decongestants be used
in adults with acute bacterial rhinosinusitis?
Q4: Should intranasal decongestants versus oral decongestants be used in adults
with acute bacterial rhinosinusitis?
Q1 and Q2 in the above example could be asked: “Should oral decongestants versus no
oral decongestants be used in patients with acute bacterial rhinosinusitis?”, if the panel believes
that these medications act similarly enough in adults and children to warrant one
recommendation for all patients irrespective of age.
†† Centre for Evidence-Based Medicine, Institute of Health Sciences Old Road Campus, Headington, Oxford, OX3
7LF, United Kingdom. http://www.cebm.net/focus_quest.asp
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When asking these questions it is helpful to think of all outcomes of interest that would
be important to patients, both desirable (e.g. less symptoms, better quality of life) and
undesirable (e.g. adverse effects, burden, cost, antimicrobial resistance).
Example:
Q: Should amoxicillin with clavulanate be given for 2 weeks rather than for 1 week in
adults with acute bacterial rhinosinusitis?
P: adults with acute bacterial rhinosinusitis
I: amoxicillin with clavulanate for 2 weeks
C: amoxicillin with clavulanate for 1 week
O: resolution of symptoms (e.g. facial pain, nasal congestion), development of
complications, antibiotic resistance, cost etc.
Please note that all outcomes but antibiotic resistance are directly important to patients
(patient perspective), however antimicrobial resistance may also be important but from a
different perspective – that of the society as a whole. It helps to make the choice of
perspective in the guidelines clear.
A guideline development panel should take the following steps when developing clinical
questions:
1. Develop clinical questions into those that are either “facts” or “action”
2. Specifying all alternative management options for a given clinical situation
3. Formulating questions about action in PICO format (specifying all outcomes of interest
for each question).
a. This may generate a long list of questions that the panel will likely have to discuss
and prioritize to make it manageable.
Figure 2
Comprehensive Literature Search Process
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Researching the Evidence
Once the scope and clinical questions of the guideline have been determined, a
comprehensive search of the literature search takes place. A key component to the development
of clinical practice guideline methodology is the creation of recommendations based on the
entirety of the evidence currently available. The Institute of Medicine describes literature
searching as the key step in developing valid guidelines. Panels will work with a designated
medical librarian to conduct searches of the literature and identify relevant evidence via
systematic searches of appropriate databases (e.g., PubMed).
Unpublished Data
Guideline writers are frequently familiar with data from abstracts and late breaking
clinical trials that may impact the guideline's content. Generally, results from unpublished data
are not acceptable. However, in special circumstances, unpublished data can be permitted if it is
no older than 2 years and is clearly stated as such in the guideline text. Only trials presented at
a major national or international scientific meeting should be considered, and should not be
used to support any recommendation. When trial data are discussed, the text should clearly
state that the data are preliminary.
Standard Guideline Format
IDSA guideline manuscripts should conform to a standardized format (See Section 3.0.
IDSA Standard Guideline Format).
Synthesis and Interpretation of the Evidence
Narrative Synthesis of Evidence
Summaries of evidence should generally be in tabular form and not in the text of the
guideline. Text should be reserved for qualifying or clarifying the recommendations. Clinical
trial data and other evidence should be displayed in an evidence table. When multiple trials have
yielded similar, non-controversial results, a single sentence with appropriate references may
suffice. Long, descriptive paragraphs of the methodology and findings of individual trials are
discouraged.
Recommendations
Guideline development, unlike other methodologies, goes beyond the compilation and
analysis of data to include recommendations that guide clinical practice. Guideline writers are
challenged with considering a vast array of evidence and creating clinically applicable and clear
recommendations from it.
As the evidence is considered, conclusions and recommendations naturally evolve.
Whenever this occurs, the recommendation should be condensed into a sentence or two and
separated from the text. The recommendations are the core guideline content, while the text
enhances the recommendations by providing further descriptive information, such as exceptions
to the recommendations and clinical options.
Guidelines are intended to be applied by health care providers at point of care. Therefore,
recommendations should be practical, supported by evidence (e.g., provide references when
possible), feasible and clinically flexible, thus facilitating the translation and implementation of
recommendations.
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Interpretation and Classification of the Evidence
Only in rare instances is there an abundance of evidence available that leads directly to an
indisputable recommendation. Expert interpretation serves as a funnel through which evidence
on multiple questions and clinical situations is combined, condensed, and formulated into
recommendations [4]. Despite all the evidence that may be available for writing
recommendations, expert interpretation will always be necessary.
Unfortunately, most evidence falls into the "gray zone" of uncertainty. The evidence
from different trials may come to divergent conclusions. The evidence may only apply to
specific sub-populations, the evidence may be from methodologically weak studies, or the
evidence may simply be insufficient to make a decision. In these instances, it is appropriate to
rely on expert opinion so long as it is clearly indicated and attributed. The basis on which expert
opinion was formed should also be specified.
The following are qualities of recommendations that may be considered when writing the
guideline:
Separate recommendations should be written that apply to specific clinical objectives
Recommendations should be written so that they are practical at point of care
Unambiguous language and clearly defined terms should be used when writing
recommendations
Information that contains areas of uncertainty or controversy should be documented
within the recommendation
Write recommendations that incorporate data on patient preferences, when applicable
Specify sub-population variability and exceptions in the recommendations. List the
exceptions whenever possible
Include flexibility in applying the recommendations, where applicable
Recommendations must be consistent with previous IDSA guidelines/statements,
unless new evidence exists to justify a change. Both the new evidence and the change
should be described in detail
Assigning Strength of Recommendations and Quality of Evidence
IDSA Clinical practice guidelines initiated in October 2008 or later will use the Grades of
Recommendation, Assessment, Development, and Evaluation (GRADE) method to assign to
strength of recommendation and quality of evidence to each recommendation (See Figure 3[5]).
Online training modules/tutorials and other information on the GRADE system can be found on
the IDSA website.
Quality of Evidence
The quality of evidence reflects the extent to which the confidence in estimates of the
effects is adequate to support a particular recommendation. Hence, judgments about the quality
of evidence are always made relative to the specific context in which this evidence is used.
GRADE offers four levels of the quality of evidence: high, moderate, low, and very low. In the
GRADE system basic study design remains an important determinant of the quality of evidence:
randomised trials begin as high quality evidence and observational studies as low quality
evidence. However, additional limitations or merits may decrease or increase the quality of
evidence. Quality of the available evidence may be downgraded as a result of the risk of bias
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(limitations in study design or implementation), imprecision of estimates (wide confidence
intervals), variability in results (inconsistency), indirectness of evidence, or publication bias.
Quality of evidence may also be upgraded because of a very large magnitude of effect, a dose-
response gradient, and if all plausible biases would reduce an apparent treatment effect.
Strength of Recommendation
The strength of recommendation reflects the extent to which one can be confident that the
desirable consequences of an intervention outweigh the undesirable ones. The GRADE system
offers two categories of the strength of recommendations: (1) strong, and (2) weak (conditional).
It is more likely to make weak recommendations when the available evidence if of lower quality,
when the balance between desirable and undesirable consequences of the intervention is not
clear, and when the values and preferences of those for whom the recommendations are made are
either not known or are known to vary widely.
Strong: For a guideline panel to offer a strong recommendation, it has to be quite certain about
the various factors that influence the strength of a recommendation and have the relevant
information at hand that supports a clear balance toward either the benefits (to recommend an
action) or the downsides (to recommend against an action) that influence a recommendation. If
guideline developers are confident that the desirable effects of adherence to a recommendation
outweigh the undesirable effects, they will make a strong recommendation within the context of
a described intervention.
The implications of a strong recommendation are:
for patients – most people in your situation would want the recommended course of action
and only a small proportion would not; request discussion if the intervention is not offered
for clinicians – most patients should receive the recommended course of action
for policy makers – the recommendation can be adopted as a policy in most situations.
Weak (conditional): In situations when a guideline panel is uncertain whether the balance
between desirable and undesirable effects of an intervention is clear or when the relevant
information is not available, a guideline panel should be more cautious and, in most instances,
opt to make a weak recommendation. If guideline developers believe that benefits and downsides
are finely balanced, or appreciable uncertainty exists about the magnitude of benefits and/or
downsides, they offer a weak recommendation.
The implications of a weak recommendation are:
for patients – most people in your situation would want the recommended course of action,
but many would not
for clinicians – you should recognize that different choices will be appropriate for different
patients and that you must help each patient to arrive at a management decision consistent
with her or his values and preferences
for policy makers – policy making will require substantial debate and involvement of many
stakeholders.
Expert Opinion: Expert opinion is NOT a category of evidence as it is the most biased type of
“evidence.” Expert opinion represents an interpretation of evidence, including evidence ranging
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from observations in an expert’s own practice (uncontrolled observations) to the interpretation of
RCTs and meta-analyses known to the expert in the context of other experiences and knowledge.
That said, in certain circumstances, observational studies, case reports or other such type
information as well as the collective experience/observations of the group may be used in some
circumstances. An example of collective experience/observations would be that 5 out of 10 of
the panel members have seen x condition and this x is what has been done.
The Panel should do the following when there’s limited or no evidence and they feel compelled
to make a recommendation:
come to agreement on what type(s) of information should be used (small observational
studies etc., and/or collective experience/observations of panel members)
Deliberations about the types of evidence used, votes taken etc., must be documented
both in the notes from the meetings and within the guideline itself.
Obviously, the quality of the evidence in these instances will be “very low,” but the strength
could be “Strong.”
The key is to be transparent about what’s being done and to document what’s being/been done.
Formulating Recommendations
GRADE suggests that guidelines developers present recommendations in the active voice
and consistently use specific wording associated with strong and weak recommendations.
GRADE suggests the following wording:
for strong recommendations – "we recommend..." or “clinicians should…”
for weak recommendations – "we suggest..." or “clinicians might…”.
Recommendations should always specify the population, and unless it is obvious, the
comparator. A recommendation may be worded as follows (example):
Strong recommendation:
“For patients with chronic rhinosinusitis with nasal polyps who have nasal blockage or an
impaired sense of smell, we recommend a short course of oral glucocorticosteroids (strong
recommendation, moderate quality evidence). Remark: A typical adult regimen may be an
equivalent of prednisone 20 mg twice daily for five days, followed by 10 mg twice daily for five
days and then 10 mg daily for five days.”
Weak (conditional) recommendation:
“For patients with chronic rhinosinusitis with nasal polyps, who receive oral or intranasal
glucocorticosteroids, we suggest leukotriene receptor antagonists (weak recommendation,
moderate quality evidence). Values and preferences: This recommendation places a relatively
high value on a small reduction in symptoms with leukotriene receptor antagonists and a
relatively low value on increased resource expenditure. Remark: Evidence is available for
montelukast only.”
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Figure 3. Approach and implications to rating the quality of evidence and strength of recommendations using the
GRADE methodology (unrestricted use of the figure granted by the U.S. GRADE Network) [5] Table: GRADE's approach to rating quality of evidence (aka confidence in effect estimates) For each outcome based on a systematic review and across outcomes (lowest quality across the outcomes critical for decision making)
1. Establish initial
level of confidence
2.
Consider lowering or raising level of confidence
3. Final level of
confidence rating
Study design Initial confidence in an estimate of effect
Reasons for considering lowering or raising confidence
Confidence in an estimate of effect
across those considerations Lower if Higher if*
Randomized trials High
confidence Risk of Bias
Inconsistency
Indirectness
Imprecision
Publication bias
Large effect
Dose response
All plausible confounding & bias would reduce a
demonstrated effect
or would suggest a
spurious effect if no effect was observed
High
Moderate
Observational studies Low
confidence Low
Very low
*upgrading criteria are usually applicable to observational studies only.
1. R
atin
g th
e q
ual
ity
of
the
evid
ence
2. D
eter
min
ants
of
the
Stre
ngt
h o
f R
eco
mm
end
atio
n
Quality (certainty)
of evidence
Balance between
benefits, harms & burdens
Patients’ values &
preferences
Resources and cost
Population: Most people in this situation would want the recommended course of action and only a small proportion would not
Health care workers: Most people should receive the recommended course of action
Policy makers: The recommendation can be adapted as a policy in most situations
Population: The majority of people in this situation would want the recommended course of action, but many would not
Health care workers: Be prepared to help people to make a decision that is consistent with their own values/decision aids and shared decision making
Policy makers: There is a need for substantial debate and involvement of stakeholders
3. Im
plic
atio
n o
f th
e St
ren
gth
of
Rec
om
men
dat
ion
Stro
ng
Wea
k
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Additional criteria for applying or using the GRADE approach
One of the aims of the GRADE Working Group is to reduce unnecessary confusion
arising from multiple systems for grading evidence and recommendations. To avoid adding to
this confusion by having multiple variations of the GRADE system we suggest that the criteria
below should be met when saying that the GRADE approach was used. Also, while users may
believe there are good reasons for modifying the GRADE system, we discourage the use of
“modified” GRADE approaches that differ substantially from the approach described by the
GRADE Working Group.
However, we encourage and welcome constructive criticism of the GRADE approach,
suggestions for improvements, and involvement in the GRADE Working Group. As most
scientific approaches to advancing healthcare, the GRADE approach will continue to evolve in
response to new research and to meet the needs of authors of systematic reviews, guideline
developers and other users.
Suggested criteria for stating that the GRADE system was used:
1. The quality of evidence (confidence in the estimated effects) should be defined
consistently with the definitions (for guidelines or for systematic reviews) used by the GRADE
Working Group.
2. Explicit consideration should be given to each of the GRADE criteria for assessing the
quality of evidence (risk of bias/study limitations, directness of evidence, consistency and
precision of results, risk of publication bias, magnitude of the effect, dose-response gradient, and
influence of residual plausible confounding) although different terminology may be used.
3. The quality of evidence (confidence in the estimated effects) should be assessed for each
important outcome and expressed using four categories (e.g. high, moderate, low, very low) or, if
justified, three categories (e.g. high, moderate, and low [low and very low reduced to one
category]) based on consideration of the above factors (#2) with suggested interpretation of each
category that is consistent with the interpretation used by the GRADE Working Group.
4. Evidence summaries (evidence tables or detailed narrative summaries of evidence
transparently describing judgements about the factors in #2) should be used as the basis for
judgements about the quality of evidence and the strength of recommendations. Ideally, full
evidence profiles suggested by the GRADE Working Group should be used and these should be
based on systematic reviews. At a minimum, the evidence that was assessed and the methods that
were used to identify and appraise that evidence should be clearly described. In particular,
reasons for upgrading and downgrading the quality of evidence should be described
transparently.
5. Explicit consideration should be given to each of the GRADE criteria for assessing the
strength of a recommendation (the balance of desirable and undesirable consequences, quality of
evidence, values and preferences, and resource use) and a general approach should be reported
(e.g. if and how costs were considered, whose values and preferences were assumed, etc.).
6. The strength of recommendations for or against a management option should be expressed
using two categories (weak and strong) and the definitions/interpretation for each category
should be consistent with those used by the GRADE Working Group. Different terminology to
express weak and strong recommendations may be used (e.g. alternative wording for weak
recommendations is: conditional), although the interpretation and implications should be
preserved.
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7. Ideally, decisions about the strength of the recommendations should be transparently
reported.
Identifying Limitations in Literature Searches and Areas for Ongoing and Future Research
Guidelines should comment on studies in progress that may help answer the clinical
question more definitively and suggest areas for further study. The process of guideline
development serves as a natural channel by which to identify research gaps which, if
appropriately addressed, can advance future clinical care and treatment. Clinical practice
guidelines identify important clinical questions and identify the quality of evidence supporting
those recommendations. Thus, guidelines should include comments on studies in progress that
may help answer clinical questions more definitively and suggest areas for further study.
Review and Approval Process
External “Peer” Review
External review is an integral step in the development of practice guidelines. The process
of external review provides critical feedback into the comprehensiveness, validity and usability
of the work performed.
Following approval of the draft guideline by the expert panel, the near-final draft of the
guidelines are sent to no fewer than 3 external peer reviewers nominated by the Expert Panel
Chair. External reviewers should include:
National (and when appropriate, international) experts on the guideline topic
Representatives from the clinical practice setting
Pediatrician, when warranted
Note: At least two of the proposed outside reviewers should be IDSA members.
Final selection of external reviewers will be done by the SPCG Chair and may include
reviewers who are independent of the list provided by the Expert Panel Chair.
Once the external reviewers have been identified and approved by the SPGC Chair, the
IDSA Staff will send an e-mail invitation to review along with a disclosure of interest form. The
form must be completed and submitted to the IDSA for review and approval by the SPGC Chair.
Once approved, the draft guideline and comment form will be forwarded onto the reviewer(s).
External reviewers are asked to provide their review within a 4 week timeframe.
Additional time may be granted if needed. Reviewer comments will be sent back to the IDSA
staff, compiled and distributed to the Panel Chair for response.
Stakeholder Review
When a stakeholder organization is involved in the development of an IDSA guideline at
the onset or is identified later in the process as a potential endorser, IDSA staff will solicit their
input and endorsement as follows:
An e-mail request is sent that includes an endorsement form and the draft guideline. The
organization that IDSA is seeking endorsement from has the opportunity to provide comments
and suggested revisions within a reasonable timeframe (4-8 weeks). The organization is
provided with the following options for their level of endorsement:
X organization endorses the guideline as written
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X organization endorses the guideline and suggests the attached comments for
consideration
X organization endorses the guideline on the condition that the attached comments are
incorporated
X organization does not endorse the guideline
If an organization is able to complete the review within the 2-month timeframe (or within
a reasonable and agreed upon timeframe), the organization will be acknowledged within the
manuscript prior to publication; however, if the organization is not able to meet the deadline, the
guideline will continue through the review process and the organization may be acknowledged
on the IDSA Website.
Once in receipt of the external reviewers’ and the stakeholder organization’s comments
(if applicable) the Panel Chair will review the comments and incorporate them into the draft as
deemed appropriate. The Panel Chair should provide (to IDSA) the revised guideline draft along
with a response to each comment made, within a reasonable timeframe (typically 2 – 4 weeks)
Responses should indicate where and why reviewer recommendations were included, and why
others were not (if applicable).
SPGC Review
The SPGC Chair will designate 1-2 primary reviewers among the members of the
Committee to review the guideline typically within a 2 – 4 week timeframe. The Panels
responses to the external reviewers’ comments will also be provided. The full Committee has
the opportunity to review and provide comments on the guideline at this time as well.
Primary reviewers should consider the following questions when reviewing the guideline:
Are the recommendations within the stated purpose and scope of the guideline?
Are all recommendations referenced appropriately?
Are all recommendations graded?
Are clinically important and feasible recommendations made?
Are areas of uncertainty and exceptions clearly identified?
Are evidence tables and appropriate text provided to support recommendations, where
applicable?
Are recommendations and key clinical points displayed in a table when possible?
Are the recommendations consistent with other IDSA documents?
Comments received from the SPGC are forwarded on to the Panel Chair for incorporation
into the draft as deemed appropriate. Within 2-4 weeks, the Panel Chair must provide (to IDSA)
the revised guideline draft along with response to each of the comments made indicating where
and why reviewer recommendations were included, and why others were not (if applicable).
Staff will then send the guideline and responses to the comments back to the SPGC for approval
(within ~1 week).
Board of Directors Review
Once approved by the SPGC, the guideline will be submitted to the Board of Directors
as follows:
The Board liaison to the SPGC will identify 1-2 primary Board reviewers to review the
guideline (responses to comments from the external review and the SPGC review will
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also be provided). The full Board has the opportunity to review and provide comments
on the guideline at this time as well.
The Board is typically given 3-4 weeks to review the document.
Comments received by the Board are forwarded on to the Panel Chair for incorporation into
the draft as deemed appropriate. Within 2-4 weeks, the Panel Chair must provide (to IDSA) the
revised guideline draft along with a response to each of the comments made indicating where
and why reviewer recommendations were included, and why others were not (if applicable).
The guideline and responses to the comments are then sent back to the Board for
approval (within ~1 week).
Pre-Publication & Publication Process
Once approved by the IDSA Board of Directors, the guideline will be submitted for
publication in the Clinical Infectious Disease (CID) with the understanding that publication is
ultimately the decision of the Editor. As of 2010, full text of IDSA Guidelines will appear in
electronic format only, with an executive summary in print. Guidelines must continue to adhere
to a strict page limit (see section below on format).
Panel members are required to observe a strict policy of confidentiality of guideline
documents, draft and final, pending guideline publication and are required to keep content of
panel deliberations confidential.
Guideline Derivatives
Panel Chair(s) will be asked to assist in the review of a number of potential derivative
products. The Chair(s) are expected to carefully review these products to ensure that the content
is consistent with the published guideline. The purpose of these products is to more widely
disseminate, in a practical and user-friendly form, the recommendations contained in the
guidelines.
Ideally, these companion products will be developed as the first full draft of the guideline
document is assembled and circulated for review, aiming for joint approval and release.
Examples of guideline derivatives include:
o Mobile Device (iPhone, iPad, Droid, etc)
o Pocketcards
o National Guideline Clearinghouse Summary
o Slide Sets
o others
Process for Guidelines Developed Jointly (Co-Sponsorship) with Other Organizations
It may be appropriate and desirable to develop guidelines in conjunction with other
organizations. This means that each organization will have a co-chair, equal representation on
the Panel and share costs associated with the development of the guideline. In such cases, the
development process should be defined and agreed upon with a memo of understanding from the
onset, including:
1. A clear understanding of the topic and purpose of the guideline
2. The composition of the development panel
3. Full disclosure of conflict of interest
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4. Expense-sharing arrangements
5. The review and approval process necessary for each organization
6. Publication rights (including responsibilities for derivatives)
It is preferable to have the guideline published in CID. However, when it is determined
that the guideline is to be published in another journal, an IDSA member serving on the
development panel may be identified to write an executive summary article for submission to
CID.
HIV-Related Guidelines
On any guideline related to HIV, suggestions will be sought from HIVMA on possible
members for the development panel.
The development process is virtually identical to the process described above, with the
exception that guidelines on HIV will be submitted to the HIVMA Board for review and
approval at the same time as for the IDSA Board.
Author Permission to Use Guideline Content
Authors retain the right to use all or part of an article in the preparation of derivative
works, provided they include full acknowledgment of the original source. So for non-
commercial purposes, authors do not need to apply for written permission from the IDSA or
CID/OUP
For commercial purposes (e.g., a book that will be sold) permission is required. You
can acquire permission through OUP’s Rights & Permissions department, but the easier method
is to go thru www.copyright.com.
GUIDELINE UPDATES, PARTIAL UPDATES AND INTERIM RECOMMENDATIONS
Guideline Update (Full)
Maintaining guideline content that is up-to-date with the clinical evidence and best
practices in the field of infectious diseases is a challenge. It requires commitment to resources to
monitor the emerging literature so that decisions as to whether or not a guideline should be
revised, or if it has become obsolete. On average, all guidelines will be reviewed for changes
and/or updates every 12-18 months.
Situations in which an evidence-based guideline might be updated include:
Changes in the evidence on existing benefits and harms
Changes in the outcomes which were considered important
Changes in available interventions
Changes in the evidence that current practice is optimal
Changes in the values placed on outcomes
Changes in the resources available in healthcare
IDSA Staff will contact the former expert panel chair(s) 12-18 months post-publication of
the guideline and request that the chair complete an evaluation form. It is expected that the
expert panel chair will continually monitor the literature for new developments that might have
an effect on the current guideline recommendations. If such new data arise in between the
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publication and this 12-18 month contact period, the chair should inform IDSA so that further
discussion and plans can be made for the initiation of an update. Guideline updates should focus
on substantive changes to recommendations.
In addition to determining whether new evidence or developments exist in the field that
potentially invalidate the current recommendations, the panel should discuss the need for new
recommendations on areas within the context of the current guideline that may have been
previously excluded for various reasons, or that have recently arisen.
Once the decision has been made to update a guideline, an expert panel will be convened.
The expert panel may include many of the preceding panelists, but must include at least two (2)
new members. As with new guideline panels, membership is reviewed and approved by the
SPGC chair. All guideline panel chairs and panel members, must comply with the current IDSA
disclosure of interests policy for guideline panels.
The process for conducting a full update, including the review and approval of the
manuscript, are the same as for an original guideline.
Criteria for the conduct of partial updates/revisions
IDSA guidelines are currently reviewed every 12 – 18 months following publication to
determine whether there is new evidence or a change in practice that would warrant a change to a
guideline. In some cases, evidence on a particular topic may evolve very quickly and require a
more immediate review than the 12-18 month review timeframe requires.
In some cases, when a small proportion of recommendations (<25%) in a guideline need to
be updated/revised, a partial update/revision may be considered IF all of the following criteria
are met:
1. The guideline in question was developed using the GRADE system
2. The guideline is less than 5 years old. A guideline that is 5 years or older should either
undergo a full update, or if no longer relevant/necessary, retired.
3. New evidence* or a change/shift in practice that effects patient care, resulting in a
substantive change to the guideline. A substantive change would be:
a. a change to a current recommendation(s) and/or a key portion of the text, and/or
b. the addition of a new recommendation(s) that must be instituted immediately
(unable to wait until the full update of the guideline)
*The publication of new evidence/reference(s) that further support an already published
recommendation or text within the guideline does not in and of itself constitute the need
for a partial update/revision. Abstracts from meetings may not serve as the basis of a
change to a guideline recommendation.
Process for proposing and carrying out a partial update/revision (<5 years)
1. If during the 12 – 18 month review and following a literature search of the evidence since
the last publication, a panel chair, in consultation with the guideline panel, find that the
above criteria are met, a partial update/revision may be proposed to the Standards and
Practice Guidelines Committee (SPGC).
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2. Once considered and approved by the SPGC, the partial update/revision will be added to
the IDSA guidelines slate and an estimate for initiation will be provided by the IDSA
Staff.
3. The process for partial update/revision shall follow the same process as that of full
guideline development/updating per the IDSA handbook on guideline development. This
includes but is not limited to panel formation, COI, review and approval processes.
4. A partial update/revision will include the following sections:
a. Brief Abstract
b. Introduction: brief rationale for carrying out partial update/revision and process
used, including literature search. Care should be taken to provide proper linkage
to the primary guideline.
c. Key Changes: If a change to a current recommendation, list the current
recommendation (e.g., 2010 recommendation) followed by the new/revised
recommendation(s) (e.g., 2013 recommendation), followed by the summary of the
evidence in support of the recommendation(s).
d. Acknowledgements – Includes listing of COI disclosures
e. Tables: If needed
f. References
Publication of a partial update/revision
A partial update/revision will be submitted for publication in the IDSA journal, Clinical
Infectious Diseases (CID). If accepted by the Editor, the update/revision will be published
Online, and possibly in print if it is concise.
Criteria for Interim Recommendations
Purpose
In order to more rapidly address new and significant information related to an IDSA guideline, a
new classification of recommendations is proposed.
In the event that a new and significant piece of evidence is published‡‡
, a new therapy becomes
available that would replace current therapy, or there is a profound change/shift in practice that is
in direct conflict with a published IDSA guideline recommendation, an INTERIM
Recommendation may be considered. Such information would directly affect the
morbidity/mortality of a population for which an IDSA guideline recommendation covers. The
goal of an INTERIM Recommendation is that it be developed quickly (within 2 – 4 months) and
that it serves as temporary guidance pending a more rigorous review of the evidence. It will
address an immediate problem/issue, guidance which cannot wait for the more lengthy and
rigorous process of an update (partial or full). An INTERIM Recommendation is not a
permanent solution, is not relevant in every situation and will not serve as a replacement for a
guideline update.
‡‡ Does not include abstract data.
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Because an INTERIM Recommendation(s) is not subjected to the same rigor that a typical IDSA
guideline is, it is not GRADE-ed and may be made regardless of the use of the GRADE
system in the previous iteration of the guideline. However, if an INTERIM Recommendation
that results in a change is made, it will serve as a trigger to carry out§§
either:
a PARTIAL Update (if the guideline is already in the GRADE system) and only a few
key changes are required. See criteria for PARTIAL Update below. OR
a FULL Update, should there be several significant changes/additions due to the new
literature, or if there had previously been one or more PARTIAL Update(s) carried out on
the topic, making it difficult for the reader to follow or have a clear picture of the
guideline so that carrying out a FULL Update will bring it all back together.
Process
Regardless of how the information is acquired (annual guideline review, Pubmed alerts, etc), a
core team (former panel chair***
, SPGC Chair, SPGC liaison to the Board) will be brought
together via conference call to determine the need for an INTERIM Recommendation (i.e., is
patient morbidity/mortality at stake (or thought to be at stake)).
An INTERIM Recommendation may take one of two forms:
o Change Required – New evidence is clear that a change should be made.
o No Change Recommended – New evidence is unclear, or consensus among panel
members cannot be attained and a watchful waiting approach to the evidence
should be taken. (Note: The “trigger” noted above will not be in effect in this
situation.)
Once it is determined that an INTERIM Recommendation is needed, a panel, many of
whom may have participated in the previous iteration, will be established.
COI’s will be updated/collected from all participants however having a relationship may
not necessarily exclude a participant.
The panel will review the new evidence, deliberate via conference call and electronically
and develop the recommendation(s), along with a summary of the evidence for which the
recommendation is based (including available references).
Draft recommendation(s) will be circulated among panel members. Votes on all changes
will be taken through a survey tool such as Survey Monkey. Consensus is defined as at
least 80% agreement among panel members. This 80% must be reached in order to make
a change. Dissenting views will be stated.
Recommendation(s) will next be reviewed and approved by the IDSA SPGC and Board
simultaneously.
Once approved, the INTERIM Recommendation will be announced and disseminated to
the IDSA membership as described below.
Format
§§ Timing of update will be dependent on current workload. When triggered, an update will be initiated as soon as
the slate of guidelines allows. *** Assumes that the former chair is still willing to assist AND that he/she has a proven track record of completing
tasks on time.
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The recommendation(s) will take a similar format to that of original IDSA guideline
recommendations. Example:
Background: Methodology used (Description of process used to form panel, gather
information, deliberate, vote, etc.).
Original Clinical Question: State relevant clinical question.
Original Recommendation: State original recommendation.
INTERIM Recommendation: State revised recommendation OR that “No Change
Recommended at this time.”
Votes Taken (if applicable):
Summary of the Evidence: Summarize evidence that supports the new
recommendation or why the panel is unable to make a change (references).
Informing IDSA Members/Others
These INTERIM Recommendations shall reside on the IDSA website (within the guidelines
section) and every attempt shall be made to assure proper linkage between these and the original
guidelines (on the IDSA website, CID, etc).
A clear indication of the purpose and process used in making the INTERIM Recommendation
along with an indication of the action it triggers (i.e., full or partial update), a projected timeline
for partial/full update, as well as the disclosures of those panel members that participated in the
development of the recommendation(s) review shall accompany the posting of the INTERIM
Recommendation.
As is usual fashion, IDSA members will be informed of INTERIM Recommendations via direct
e-mail and posting on the IDSA website. CID/OUP will also post a linkage/indication of change
on the CID website (pending verification with CID/OUP).
FAQ
What an INTERIM Recommendation is:
IS temporary.
IS evidence-based ‘opinion’.
IS a thoughtful, but concise and expedited review and deliberation of new and practice
changing information by experts identified by IDSA, in order to provide more immediate
guidance and pending a more rigorous, full review and update.
IS reviewed and approved by the IDSA Standards and Practice Guidelines Committee
and Board of Directors.
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What an INTERIM Recommendation is not:
NOT based on a Systematic Review of the evidence.
NOT GRADE-ed.
NOT a replacement for an individual clinicians’ clinical judgment. It [INTERIM
recommendation], along with all other information available should be carefully
reviewed and considered.
IDSA STANDARD GUIDELINE FORMAT
IDSA guideline manuscripts should follow the format listed below. Guideline sections
are listed, with annotation and sample wording as needed. Guidelines are most useful when they
are both complete and concise; the guideline should not exceed 50 double-spaced pages
(excluding tables and references).
Title Page
The title should take the following form:
“Treatment/Use of X in X: Clinical Practice Guidelines by the Infectious Diseases Society of
America (IDSA)” (e.g., The treatment of fever and neutropenia in cancer patients: clinical
practice guidelines by the Infectious Diseases Society of America (IDSA))
The short title (for the running foot) will take the form of “IDSA X Guidelines” (e.g., “IDSA
Fever and Neutropenia Guidelines”)
If the document is an update to a previously published guideline the title should read: Clinical
Practice Guidelines for the use of X in X: 2013 Update by the Infectious Diseases Society of
America*
The title must be followed by an asterisk (*) that will lead the reader to a footnote on page one
that states IDSA’s disclaimer:
“It is important to realize that guidelines cannot always account for
individual variation
among patients. They are not intended to supplant physician judgment with respect to
particular patients or special clinical situations. IDSA considers
adherence to these
guidelines to be voluntary, with the ultimate determination regarding their application to
be made by the physician in the light of each patient’s individual circumstances.”
Executive Summary
The Executive Summary is the only part of the guideline published in print and will
include a brief introduction followed by a listing of the recommendations within the guideline.
The following paragraph should be included within the introduction, just prior to the listing of
recommendations:
“Summarized below are the recommendations made in the new guidelines for X.
A detailed description of the methods, background, and evidence summaries that
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support each of the recommendations can be found online in the full text of the
guidelines.”
Note: Although the full guideline is being published online only, Panels still
must maintain the page limits set for the guideline (50 manuscript pages).
Introduction
This section outlines in 1-2 manuscript pages the rationale for the guideline in terms of
the questions addressed in the original topic proposal, i.e., burden of the condition or importance
of the health care intervention, controversy or uncertainty concerning appropriate management or
use, perceived or documented variation in practice and need for guidelines to facilitate decision-
making in clinical practice.
Clinical Questions: List the clinical questions to be addressed by the guideline.
Practice Guidelines
This section is boilerplate material that defines practice guidelines and outlines attributes
of good guidelines. The section concludes with legal boilerplate material that underscores the
voluntary nature of adherence to the guideline and the critical role of individual physician
judgment. Language follows:
“Practice guidelines are systematically developed statements to assist practitioners and
patients in making decisions about appropriate health care for specific clinical
circumstances [6]. Attributes of good guidelines include validity, reliability,
reproducibility, clinical applicability, clinical flexibility, clarity, multidisciplinary
process, review of evidence and documentation [6].
Methods
The methodology section of the guideline is mostly boilerplate and includes subsections
that, among other things, describe the composition of the panel, how the literature was reviewed
and the yield, what the process was that was used in the guidelines development. Although this
section does add to the overall length of the guideline, it is critical in providing transparency
about the process and conclusions.
Note: Limit to 3-6 manuscript pages, and include the following subsections (sample
wording is provided):
Panel Composition: “A panel of experts composed of infectious disease specialists, X, X, X and
X with an expertise in X disease was convened. Both
academic and community practitioners
were included.
Literature Review and Analysis: Describes the methodology of the literature review from
beginning to end and includes databases searched (e.g., PubMed, Cochrane Library), search
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terms used, the inclusion and exclusion criteria employed, the abstract review processes, and so
on.
Process Overview: In evaluating the evidence regarding the management of X, the Panel
followed a process developed by the Grades of Recommendation, Assessment, Development,
and Evaluation (GRADE) Working Group (http://www.gradeworkinggroup.org/). The process
included a systematic weighting of the quality of the evidence and the grading of
recommendations (Table X).
Consensus Development Based on Evidence: Boilerplate “The entire Panel met X number of
times. All members of the Panel participated in the preparation of the draft guideline,
which was
then disseminated for review by the entire Panel. Feedback from external reviewers was also
solicited (See Section 3.12. Acknowledgements). The content of the guideline and the manuscript
were reviewed and approved by the SPGC and by the IDSA Board of Directors before
dissemination.”
Guidelines and Conflict of Interest: Boilerplate “All members of the Expert Panel complied
with the IDSA Disclosure of Interests Policy for Clinical Practice Guidelines, which requires
disclosure of any potential conflict of interest and to abstain from any decision where a potential
conflict of interest exists. In order to provide thorough transparency, the IDSA requires full
disclosure of all relationships, regardless of relevancy to the guideline topic. Evaluation of such
relationships as potential conflicts of interest is determined by a review process which includes
assessment by the SPGC Chair, the SPGC liaison to the Panel, the BOD liaison to the SPGC and
if necessary, the COI Task Force of the Board. This assessment of disclosed relationships for
possible COI will be based on the relative weight of the financial relationship (i.e., monetary
amount) and the relevance of the relationship (i.e., the degree to which an association might
reasonably be interpreted by an independent observer as related to the topic or recommendation
of consideration).
Revision Dates: Boilerplate “At annual intervals, the SPGC will determine the need for
revisions to the guideline based on an examination of current literature.
If necessary, a Panel will
be convened (or reconvened) to discuss potential changes.
Summary of Outcomes Assessed: Describes the outcomes considered in the guideline and what
information has been/can be drawn from the initial outline.
Recommendations
Clinical Question 1 (List first clinical question here)
Recommendation: Succinct recommendations with references should be listed here
[Strength of Recommendation and Quality of Evidence] (See Table 2 in Section 2.9.
Assigning Strength of Recommendations and Quality of Evidence).
Evidence Summary: This section should provide a synopsis of the supporting evidence.
Subsequent topically organized subsections can be used to review specific study results in
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detail. Pertinent data in support of the recommendation should be presented in tabular
form wherever possible.
Note: After reading the evidence summary, the guideline user should be able to
delineate the bases for the practice recommendation.
Clinical Question 2 (List second clinical question here)
Recommendation: Succinct recommendations with references should be listed here
[Strength of Recommendation and Quality of Evidence] (See Table 2 in Section 2.9.
Assigning Strength of Recommendations and Quality of Evidence).
Evidence Summary: See above for guidance.
Limitations of the Literature and Ongoing and Future Studies
Guidelines should comment on studies in progress that may help answer the clinical
question more definitively and suggest areas for further study. The process of guidelines
development serves as a natural channel by which to identify research gaps which, if
appropriately addressed, can advance future clinical care and treatment. Clinical practice
guidelines identify important clinical questions and identify the quality of evidence supporting
those recommendations. Thus, guidelines should include comments on studies in progress that
may help answer clinical questions more definitively and suggest areas for further study.
Principles to be considered when proposing and prioritizing research topics include clinical
consequences/burden of disease, feasibility, economic consequences, broadness of applicability,
and degree of uncertainty.
Acknowledgments
Boilerplate: “The expert panel expresses its gratitude for thoughtful reviews of an earlier
version by…”.
Funding: The guideline was funded by the Infectious Diseases Society of America.
Potential Conflict of Interest:
When IDSA publishes a guideline in one of its journals, all disclosures of panel members
will be published concurrently. The following language will accompany the list of disclosures
within the “Acknowledgements” section:
“The following list is a reflection of what has been reported to the IDSA. In order to
provide thorough transparency, the IDSA requires full disclosure of all relationships, regardless
of relevancy to the guideline topic. Evaluation of such relationships as potential conflicts of
interest is determined by a review process which includes assessment by the SPGC Chair, the
SPGC liaison to the development panel and the BOD liaison to the SPGC and if necessary, the
COI Task Force of the Board. This assessment of disclosed relationships for possible COI will
be based on the relative weight of the financial relationship (i.e., monetary amount) and the
relevance of the relationship (i.e., the degree to which an association might reasonably be
interpreted by an independent observer as related to the topic or recommendation of
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consideration). The reader of these guidelines should be mindful of this when the list of
disclosures is reviewed.”
Tables, Figures and other Artwork
The total number of tables, figures and other artwork should generally not exceed 10. The
first table should outline the IDSA grading system for ranking recommendations in clinical
guidelines (GRADE). Remaining tables and figures should serve as easy references for clinicians
making diagnoses and treatment decisions. Any tables, figures or other artwork that are adapted
from other sources must have permission to use/adapt/reprint the information from the originator
before the guideline is submitted for publication. Exception is when a table, figure etc., is
published in an IDSA journal (CID/JID). Tables, figures and other artwork should follow the
same general format that is outlined on the CID website
(http://www.journals.uchicago.edu/page/cid/msprep-tables.html;
http://www.journals.uchicago.edu/page/cid/msprep-art.html)
References
Self-explanatory.
GUIDELINE RETIREMENT
A guideline may be considered for retirement if its recommendations no longer apply or
are adequately covered and more rapidly updated elsewhere, rendering any attempt by IDSA to
carry out an update, repetitive and costly. As guidelines are evaluated by the SPGC for need for
update, retirement will be considered. If retired, a notification will be made on the IDSA website
and will include information and links to other relevant resources when appropriate.
RELATED GUIDELINE INFORMATION
Guideline Policy Internal and External Usage
IDSA Guidelines serve as an integral part of the organizations communication regarding
evidence-based research used in the infectious diseases arena. Many times, IDSA members and
the public request to discuss and/or use the guideline at various conferences and CME activities.
As a result, IDSA has developed standard policies for use of these guidelines.
Policy at IDSA Meetings
The Annual IDSA Conference serves as the perfect opportunity for invited IDSA guideline
development panel chairs to present new or revised clinical practice guidelines to the IDSA
Membership during the “New Clinical Practice Guidelines Symposium”.
During these presentations, specific recommendations should not be considered final nor
should they be reproduced or disseminated in any form by unauthorized individuals or groups
until fully vetted, approved and published by the IDSA (and its collaborators).
Policy for Outside IDSA Meetings and Industry-sponsored Symposia
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IDSA Guidelines that are in development (i.e., they have not been reviewed and approved
by IDSA or its collaborators) WILL NOT be presented at any Meeting outside of the IDSA
Annual Meeting SPGC-Sponsored Symposium without the approval of the IDSA Staff and
SPGC Chair. Recommendations and specific text are not permitted for dissemination nor should
they be discussed in detail at these sessions.
4.1.3. Policy for Continuing Medical Education Activities
IDSA Guidelines that are in development (i.e., they have not been reviewed and approved
by IDSA or its collaborators) WILL NOT be used by any entity to develop any continuing
educational activity, tools or products.
Published IDSA Guidelines may be discussed and/or disseminated provided that:
1. IDSA Headquarters reviews and approves the CME activity content before finalized
and disseminated
2. That proper acknowledgement of the IDSA is given and that the published article is
referenced appropriately.
Policy for Organizations Seeking IDSA Endorsement
The IDSA acknowledges that many organizations are producing quality guidelines that
are relevant and appropriate to the mission and interests of IDSA and its membership. IDSA is
committed to systematically evaluating these guidelines and disseminating them as appropriate
to its membership.
Endorsement Process
The primary criteria used to assess guidelines submitted for endorsement is the quality of
the process used to develop the document. This includes an assessment of the use of evidence vs.
consensus and the appropriate linkage of evidence to recommendations. The following criteria
will be applied to requests for IDSA endorsement:
A formal request has been made to IDSA
IDSA participated (officially) in the development process and is afforded the
opportunity to review (see below) and comment on the guideline before it’s made
final.
Guidelines should be relevant and appropriate to the mission and interests of
IDSA and its membership and not be duplicative of existing IDSA guidelines
Proposed guidelines for endorsement should be based on a comprehensive
literature review of the available evidence
There should be an explicit statement of the purpose, methodology utilized and
recommendations created
The proposed guideline development process is free of any inappropriate support
or influence from industry
Note: Eligibility for endorsement does not guarantee that the request for endorsement
will be accepted.
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Review Process
Guidelines submitted for endorsement by IDSA will be handled as follows:
the SPGC will review and comment on the guideline based on the above criteria and
make a recommendation to the Board for endorsement
The Board will review and comment on the guideline with the goal of endorsement
Due to time constraints, the SPGC and Board review may take place simultaneously.
IDSA encourages other organizations to inform IDSA of their intent to request
endorsement as early in the process of developing the guideline as possible.
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INTERNAL ACTIONS FOR ENDORSING OTHER ORGANIZATIONS GUIDELINES
LEVEL Circumstance Presentation/Dissemination
En
do
rsem
ent
IDSA full partner in
development of the document
o May bear IDSA logo;
o IDSA may publish an executive summary of the guideline in CID;
o IDSA may disseminate the document to its members with the permission of the
primary organization;
o IDSA may request permission to publish all, a portion or a summary of the
document on the IDSA website after publication of the article by the collaborating
organization.
IDSA provided an official
representative to the
development of the document
o May bear IDSA logo;
o IDSA may disseminate the document to its members with the permission of the
primary organization;
o IDSA may request permission to publish all, a portion of or a summary of the
document on the IDSA website after publication of the article by the collaborating
organization.
LEVEL Circumstance Presentation/Dissemination
No
En
do
rsem
ent IDSA full partner in
development of the document o IDSAs logo and/or name may not be used;
o IDSA will not disseminate the document to its membership;
o The document may not state that the IDSA endorses the document IDSA provided an official
representative to the
development of the document
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REFERENCES
1. No authors listed. Clinical Practice Guidelines We Can Trust. In: Graham R, Mancher M,
Wolman DM, Greenfield S, Steinberg E, eds.: The National Academies Press, 2011:15.
2. Kish MA. Guide to development of practice guidelines. Clin Infect Dis 2001; 32:851-4.
3. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline
development, reporting and evaluation in health care. CMAJ 2010; 182:E839-42.
4. ACC/AHA. Section II: Tools and Methods for Creating Guidelines - Step Five:
Synthesize and Interpret the Evidence; Manual for ACC/AHA Guideline Writing Committees,
2005. Available at. Accessed.
5. U.S. GRADE Network. Approach and implications to rating the quality of evidence and
strength of recommendations using the GRADE methodology, 2015. Available at:
http://www.gradeworkinggroup.org/. Accessed: July, 2015.
6. Field MJ, Lohr KN, eds. Institute of Medicine Committee to Advise the Public Health
Service on Clinical Practice Guidelines, Clinical Practice Guidelines: Directions for a New
Program. Washington, DC: National Academy Press, 1990.